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العنوان
Comparing The Outcomes Of A Modified Technique
Using A Spatulated Umbilical Cord Patch For
A Scarless Primary Repair Of Gastroschisis With
Other Techniques For Primary Closure:
المؤلف
Mansour, Sherif Mamdouh Abdelhafez.
هيئة الاعداد
باحث / Sherif Mamdouh Abdelhafez Mansour
مشرف / Osama Abd Elellah Elnaggar
مشرف / Thomas T. Tsang
مناقش / Mohamed Soliman El Debeiky
تاريخ النشر
2019.
عدد الصفحات
146 P. :
اللغة
الإنجليزية
الدرجة
الدكتوراه
التخصص
جراحة
تاريخ الإجازة
1/1/2019
مكان الإجازة
جامعة عين شمس - كلية الطب - قسم جراحة الاطفال
الفهرس
Only 14 pages are availabe for public view

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from 146

Abstract

T
here is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low-income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anaesthesia, and lack of neonatal parenteral nutrition.
Given the complexity of care required and the high resource utilization of this patient population, there has been a call for protocol-driven care. A survey of trainees in accredited pediatric surgery residency programs reported that the overwhelming majority of institutions did not have institutional protocols and variability existed in terms of practice patterns among the attending surgeons. Protocolized care that streamlines the perioperative management of patients with gastroschisis would likely reduce the variability and improve outcomes across institutions. (107)
There is no a single best technique for management of gastroschisis. There are too many factors that influence the outcomes for these patients. Hence, the choice for the closure technique should be tailored to each patient to optimize the benefit.
The primary objective of this study was to prospectively analyse the outcomes of primary closure of gastroschisis using Spatulated Umbilical Cord (SUC) technique, and then compare these outcomes with the retrospectively collected outcomes of patients who underwent primary fascial closure. We wanted to produce a generic, safe and cost-effective surgical intervention protocol which is easily reproducible and could improve the outcomes even in the low-resource settings.
The study was conducted at the Department of Paediatric Surgery at Norfolk and Norwich University Hospital NHS Foundation Trust in UK and Department of Paediatric Surgery at Ain Shams University Hospitals in Egypt, during the period from February 2017 to February 2019. 19 patients were enrolled in the study being divided into 2 groups. The study group included 9 patients; 7 from NNUH and 2 from ASUH. The control group was a retrospective cohort of 10 patients; all from NNUH, who underwent primary fascial closure.
The outcomes measured included the need for re-operation, duration of mechanical ventilation, time to start enteral feeds, time to establish goal feeds, abdominal and wound complications and other remote complications.
It should be noted that owing to the small size of the study population, inferential statistical analysis was of a limited power. Thus, in-depth descriptive analysis of various outcomes and associated risk factors was carried out.
In our study, whereas other primary fascial closure techniques were successful in all patients, spatulated umbilical cord patch technique was successful in 77.8% (7/9 patients), i.e. it failed in 2 patients who had a re-laparotomy for developing abdominal compartmental syndrome.
We didn’t find any statistically significant differences between both study groups regarding gestational age, sex, mode of delivery, birth weight or incidence of meconium-stained/offensive liquor or eventful neonatal resuscitation. However, the birth weight and gestational age were less in the study group compared to the control group. This implied that our technique can be used even in small babies with viscero-abdominal with satisfactory outcomes.
The duration of mechanical ventilation was statistically significantly shorter in the control group compared to the SUC patch technique (1.75 vs 4.0 days respectively). However, one should consider the impact of the baby’s lung maturity on the success of extubation. It should also be noted that one patient in the study group had a successful cot-side primary reduction under sedation; without general anaesthesia. This patient didn’t need any post-operative ventilation.
Time-to-start or achieve goal enteral feeding was longer in patients with SUC patch technique compared to the control techniques respectively, these differences failed to reach statistical significance.
When analyzing the operative complications, no statistically significant differences were found between the patients of both groups regarding the incidence of the different surgical complications. Two patients in the SUC patch group needed re-laparotomy after development of abdominal hypertension. Intestinal obstruction occurred in SUC patch group patient who developed abdominal hypertension and underwent subsequent staged closure; and in another patient in the control group who developed adhesive obstruction at 3 months of age that required a laparotomy.
On the follow up of the patients in the study group, the observed umbilical hernia after the umbilical cord fell had gradually closed by the fifth month in 2 patients and persisted in 1 patient at 6 months follow up. One patient in the control group had a persistent umbilical hernia that required surgical repair at 6 years of age.
In our study, we were able to prove that the primary closure of gastroschisis using SUC technique has similar; or even superior outcomes, when compared to other techniques. It should be noted that the key for the optimised outcomes is the proper patient selection to avoid unwanted complications.
However; in order to be able to generalize the technique, an RCT with a more comprehensive sample size of operative primary reduction using the spatulated umbilical cord technique versus staged reduction using a preformed silo versus primary fascial closure for simple gastroschisis is warranted.